The Emerging Role and Clinical Utility of Transnasal Transesophageal Echocardiography

Transesophageal echocardiography (TEE) is a cornerstone of cardiovascular diagnostics. A major advantage of TEE over transthoracic echo (TTE) is superior resolution of posterior structures such as the mitral valve and the left atrial appendage (LAA). TEE is invasive and requires the use of moderate and sometimes deeper levels of sedation. Anesthesia accounts for most TEE-related risks including hemodynamic (hypotension, arrythmia) and respiratory compromise. Risks of anesthesia are amplified by the high prevalence of co-morbidities in patients undergoing TEE. Anesthesia also requires specialized procedural space and skilled providers, limiting the availability of TEE, and increasing the overall cost of the procedure. Alternative TEE methods that minimize (or negate) the use of anesthesia would enhance workflow, expand availability, reduce risk, and may provide similar or more accurate information compared to conventional TEE. The nasal orifice is an alternative to the oral approach, and transnasal TEE can eliminate the need for anesthesia and expand availability of use, while minimizing risk of oropharyngeal injury. This review explores the emerging role of transnasal TEE as a viable alternative to the conventional oral approach and critically evaluates current technologies and clinical applications. Particular attention is given to unmet clinical needs, barriers to adoption, and future directions that may enable broader, safer, and more effective use of TEE in both procedural and non-procedural settings.